Manual of Office-Based Anesthesia Procedures

Abstract

In its preface, this book describes ‘office-based anesthesia (OBA)’ as the practice of ambulatory anaesthesia in an office setting! At the present time in the USA, this is an expanding market, with an increasing complexity of cases and increasing numbers of patients with associated medical problems and risk factors. In addition, patients are being sedated by non-anaesthesia personnel with a high accompanying incidence of untoward respiratory events, especially in the postoperative period! Why has this sub-speciality practice developed? The prime drivers in the USA are the need to provide facilities for minimally invasive anaesthesia and surgery, coupled with techniques to achieve large throughput with the accompanying large financial savings. The number of OBA procedures in the USA has increased by 100% over the 10 yr from 1995 to 2005. To address the issues presented by the development of this approach to the provision of surgical care, Shapiro and his colleagues (all from Harvard Medical School and related Boston hospitals) have set about producing this first comprehensive manual of OBA. In many ways, the book aims to bring together practice in the light of the ASA-produced 2002 guidelines for ‘office-based anesthesia: considerations for anesthesiologists in setting up and maintaining a safe office anesthesia environment’. These guidelines required the anaesthetist to take note of advances in preoperative and postoperative care, anaesthesia and analgesia techniques, and to help develop and provide ergonomically designed operating rooms. The practice of OBA and surgery is based on four key principles: making it official, making it pleasant, making it safe, and making it comfortable. However, to date, only 22 of the 50 States have rigid legislation to accommodate office-based surgery. In the USA, the most common OBA procedures include colonoscopy and biopsy, extracapsular cataract removal, upper gastro-intestinal endoscopy and biopsy, diagnostic or therapeutic spinal injections, debridement of skin and subcutaneous tissues, and surgical cosmetic procedures! As a rough guide to practice, OBA is made up of about 37% ophthalmologic and 33% gastro-intestinal operations, with a further 13% of cases being therapeutic pain blocks. About 48% of all cosmetic surgery is conducted in the office environment (with 91.4% of these cases being carried out in females!). Is vanity being achieved at the cost of safety? Of the 15 chapters, a number stand out as offering good advice. The chapters on preoperative assessment, anaesthetic agents, and postoperative care (including pain relief) have much to commend them. Four techniques of ‘general anaesthesia’ are recognized: minimal sedation (anxiolysis); moderate sedation and analgesia (= MAC, monitored anaesthesia care); deep sedation and analgesia; and balanced anaesthesia techniques. The other (and equally important) techniques are local anaesthesia infiltration and regional plexus blocks. At a time when there is debate over the role and place of nitrous oxide, common sense prevails—with comment that the meta-analysis from 1996 by Tramer and colleagues suggests that the emetic effect of the anaesthetic gas is not significant, hence, why not use it for its anaesthetic-sparing and analgesic properties? The authors also offer guidance over the appropriate approach to the preoperative management of patients taking herbal medicines—how often do we ask about or even consider these at preoperative assessment clinics in the UK? The future of OBA may include of the α2-agonist dexmedetomidine (if and when it is licensed for that area of use in the UK). There then follows four chapters on particular surgical specialities and how OBA may be adapted for them. Does this book have any place for the anaesthetist in the UK or Europe? At first glance, you might say no, as we do not have office-based practice in the UK. However, consider what your hospital or Trust may be asking you to do: provide pre-assessment with admission on the morning of surgery, and then aim to get the patient home that same day. Many of the perioperative principles described by Shapiro and colleagues are readily adaptable to current practice for pre-assessment of patients by nurses; postoperative care and proper provision of pain control is important for all ambulatory patients whether as OBA in the USA or as day-case patients in the UK and Europe. Many day-case units in the UK are stand-alone facilities. We cannot rely on other anaesthetic colleagues to help if we get into difficulties, and hence a sound and safe practice must be adopted. There is much wisdom in this volume and I can recommend it to those interested in day-care anaesthesia and surgery. I do not suggest that it is the guide for the UK anaesthetist to start undertaking anaesthesia and surgery in non-hospital environments without much careful fore-thought and planning. But this book will be a useful guide if you want to think about it!